Backcountry Outdoor Adventure Camp

Transcription

1 Backcountry Outdoor Adventure Camp Get outdoors. Connect with nature. Focused on combining a passion for biology, conservation, and ecology with outdoor recreation. Registration Packet is due by: Registration Packet Checklist: Section A: General o General Information o Emergency Contacts o Skills Assessment Section B: Medical Information o Medical History o Immunization Records Section C: Waivers o Authorized to Carry o HRCA General Liability & Photo Release o Horseback Riding o Rockwall Climbing o Emergency Care and Transportation If your child has a medical condition or may need over the counter medications, has allergies requiring an Epipen or asthma requiring an inhaler, we require that you download and complete the additional medical forms posted on the website where you found this packet. Packets may be mailed to: HRCA Attn: Backcountry Wilderness Area Camps 4800 McArthur Ranch Rd. Highlands Ranch, CO Or dropped off at any Highlands Ranch Community Recreation Centers with Attn: Backcountry Camps written on it. For questions, please contact: AnnaKate Hein at or AnnaKate.Hein@HRCAonline.org Page 1 of 12

2 Section A: General Information *Application Date: *Dates of Enrollment: Child Information: *Child s Name: *Date of Birth: Age: *Home Address: *Shirt Size: Youth Adult Small Medium Large X-Large Parent/Legal Guardian Information: *Parent Contact #1 Call 1 st : *Home address (if different than child s): *Place of Employment: *Employer s Address: *Home Number: Cell Number: Work Number: Preferred method of contact during camp: Home Cell Work *Parent Contact #2 Call 2 nd : *Home address (if different than child s): *Place of Employment: *Employer s Address: *Home Number: Cell Number: Work Number: Preferred method of contact during camp: Home Cell Work Is a custody order in affect? Yes No Person(s) not permitted to call for child: Medical Contacts: (These must be specific answers.) *Child s Doctor: *Phone: *Address: *Child s Dentist s: *Phone: *Address: *Hospital of Choice: *Phone: *Address: Page 2 of 12

3 Section A: Emergency Contacts Designate at least one emergency contact. Two is preferred. These can NOT be a parent or guardian. These contacts will only be contacted in the event that a parent/guardian cannot be reached. Your child will not be released to anyone other than a parent/guardian or someone signed off on this form. Photo ID is required of any adult (including parents/guardians) to pick up a child. Modifications to this list can only be made by a parent or guardian. *Emergency Contact 1: *Name: Relation to Child: *Home Address: *Home Phone: Cell Phone: Authorized to pick-up child: Yes No Emergency Contact 2: Name: Relation to Child: Home Address: Home Phone: Cell Phone: Authorized to pick-up child: Yes No *Emergency Contact 3: *Name: Relation to Child: *Home Address: *Home Phone: Cell Phone: Authorized to pick-up child: Yes No *Signature of Parent/Guardian Date Page 3 of 12

4 Section B: Skills Assessment Backcountry Camps will provide a variety of outdoor opportunities for your camper. By filling out this form, you will help staff better meet the needs of your camper. Please check one box for each activity: Swimming: My child does not know how to swim would be able to pass a basic swim test Hiking: My child has never hiked occasionally goes on hikes frequently goes on hikes Horseback Riding: My child has never been on a horse has been on a trail ride has taken riding lessons Archery: My child has never shot a bow has shot a bow Rock Wall My child has never been on a rock wall has been on a rock wall Page 4 of 12

5 Section B: Medical History The following information must be provided by the parent or guardian. The intent of this information is to provide camp personnel the background to provide appropriate care. Keep a copy of the completed forms for your records. Any changes to this form should be provided to camp personnel as soon as possible. General Questions: * Please check any of the following conditions that apply to your child and indicate the approximate dates: Asthma: Behavioral: Chicken Pox: Convulsions/Seizures: Diabetes: Nose Bleeds: Seasonal Allergies: Allergic to Horses: Other: None If yes, please explain. Include any chronic medical conditions not listed above. Note: If the participant has a history of serious illness or injury (i.e. heart murmur, epilepsy, surgery, etc.), a signed physician s note indicating the individual s ability to participate in all activities is required. Medications: List all medications (including over-the-counter and non-prescription drugs) taken routinely. Prescription medications must be in the original container/packaging with a label including the following: child s first and last name, name of prescribing physician, medication name, dosage, frequency of administration. Over-the-Counter medications must be in the original container/packaging and labeled with the child s first and last name. This person does NOT take medications on a routine basis. Or Medication 1: Dosage: Frequency: Reason for taking: Medication 2: Dosage: Frequency: Reason for taking: Medication 3: Dosage: Frequency: Reason for taking: Page 5 of 12

6 Section B: Medical History (Continued) Allergies: List all known medical allergies and only severe or life threatening food allergies. Note: If your child carries an EpiPen, the Allergy and Anaphylaxis Action Plan and Medication Orders form MUST be completed. Special Diet: If your child requires a doctor prescribed diet, please indicate diet, restrictions, and reason. Additional Information: Please provide any information regarding physical, mental, or emotional health and behavior of which camp should be aware. If your child has a medical condition or may need over the counter medications, has allergies requiring an Epi-pen or asthma requiring an inhaler, we require that you download and complete the additional medical forms posted on the website where you found this packet. Page 6 of 12

7 Section B: Immunization Record Please attach a current copy of your child s immunization records to this packet. Note that it can take up to a week to receive a copy from your physician. If your child is exempt, please read and sign the bottom of the state immunization sheet that follows. If the child is exempt for medical reasons, the child s physician must also sign. Page 7 of 12

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9 Section C: Authorization to Carry Please read and initial the following statements indicating your authorization. If you do not wish to give your authorization, do not initial, but please explain why. Transportation: I authorize the Backcountry Wilderness Area staff to transport my child while at camp. Transportation methods include 12 passenger vans and walking. I authorize the Backcountry Wilderness Area staff to transport my child to safety in the event of an emergency, evacuation or severe weather from the current location to the nearest safe location. Outdoor and Special Activities: Camp activities, including but not limited to: hiking, fishing, extended time outdoors, and active games can be physically strenuous and may involve some risk to participants. The Backcountry Wilderness Area staff take all precautions to reduce risk and provide safe, educational, and enjoyable experiences. I warrant that my child is able to follow directions for all camp activities. I acknowledge that risks from participation in camp activities exist. I have allowed my child to attend camp knowing of these risks and their possible consequences including personal injury. I understand that outdoor activities include exposure to the sun and elements that can lead to sunburn, dehydration, bug bites, skin sensitivity to grasses or other discomfort associated with the outdoors. I assume the risks inherent in outdoor activities. I authorize my child to participate in outdoor activities and will provide the appropriate materials for him/her to do so safely which include but are not limited to providing sufficient food, water and appropriate clothing. Handbook: I have read the appropriate parent handbook and have gone through it with my child. I assume responsibility for myself and my child understanding its contents. Movie Permission: I authorize my child to watch movies while at camp. All movies will be rated G or PG; all PG movies have been selectively screened before viewing. Sunscreen: I authorize the Backcountry Wilderness Area staff to apply sunscreen to my child. I will provide sunscreen labeled with my child s first and last name for application. I authorize that in the event sunscreen is forgotten, staff has permission to use NO AD SPF 30 or higher. Initial: Lip Balm/Lip Gloss: I authorize my child to bring their own lip balm or gloss and keep it on their person and apply as directed for sun protection. Page 9 of 12

10 Section C: General Liability Liability Waiver and Photo Release I understand and accept that there are risks involved in participating in any recreational activity. I understand that this is an outdoor activity which may involve walking off trail in unimproved, natural areas and may involve numerous inherent risks of injury that are an integral part of such an activity. I assume full responsibility for all such risks. I understand that I may encounter variations in terrain which may result in injury or damages. I acknowledge that these are my responsibility and I assume the risk for these hazards including breaks, growth, debris, rocks, cliffs and other hazardous surfaces or subsurface conditions and obstacles whether they are obvious or not obvious, man-made or natural. I am aware of those risks, and I am voluntarily participating in this activity with knowledge of the risks involved. I agree to accept any and all such risk of injury, death, and/or property damage. I agree to the terms of this waiver, release, covenant not to sue and indemnity agreement as set forth herein. In case of injury or illness, I give my consent to emergency transportation and the administration of first aid, medical and/or dental treatment. I accept responsibility for the payment of any emergency transportation, treatment expenses and all related or subsequent medical and/or dental bills. I acknowledge that Highlands Ranch Community Association, Inc. (Hereinafter HRCA ) has not purchased and does not provide any medical or accident insurance to cover such expenses. Any such insurance is my responsibility. I waive, release, absolve, indemnify, and agree to hold harmless HRCA, its members, officers, directors, employees, volunteers, agents, or any other representative of these entities against any and all causes of action, claims, demands, losses, expenses, ability. Any photographs taken while participating in any program, recreational activity, or event are the property of the Highlands Ranch Community Association, Inc. and may be used at their discretion. *Participant s Name *Signature of Parent/Guardian *Date Page 10 of 12

11 Section C: Horseback Riding Waiver Horseback Riding Liability Waiver I the undersigned, hereby acknowledge that I have voluntarily applied to engage in an activity of horseback riding with Highlands Ranch Community Association, Inc. I understand that the activity of horseback riding involves numerous inherent risks of injury that are an integral part of such an activity. I assume full responsibility for all such risks, including loss of control, collisions and obstacles, whether they are obvious or not obvious. I and/or my family further understand that an animal, irrespective of its training and usual past behaviors and characteristics may act or react unexpectedly or unpredictably at times and I also assume such risks. I understand that I may encounter variations in terrain which may result in injury or damages. I acknowledge that these are my responsibility and I assume the risk for these hazards including breaks, growth, debris, rocks, cliffs and other hazardous surfaces or subsurface conditions and obstacles whether they are obvious or not obvious, man-made or natural. I understand that animals are unpredictable and that the risk of injury is inherent to the activity. I agree to assume all risks of injury or death caused by horseback riding, whatever the cause, except as provided by law. I understand that helmets are provided if I so desire to wear a helmet. I understand and accept that there are risks involved in participating in any recreational activity. I understand that this is an outdoor activity which may involve walking off trail in unimproved, natural areas and may involve numerous inherent risks of injury that are an integral part of such an activity. I assume full responsibility for all such risks. I am aware of those risks, and I am voluntarily participating in this activity with knowledge of the risks involved. I agree to accept any and all such risk of injury, death, and/or property damage. I agree to the terms of this waiver, release, covenant not to sue and indemnity agreement as set forth herein. In case of injury or illness, I give my consent to emergency transportation and the administration of first aid, medical and/or dental treatment. I accept responsibility for the payment of any emergency transportation, treatment expenses and all related or subsequent medical and/or dental bills. I acknowledge that Highlands Ranch Community Association, Inc. (Hereinafter HRCA ) has not purchased and does not provide any medical or accident insurance to cover such expenses. Any such insurance is my responsibility. I waive, release, absolve, indemnify, and agree to hold harmless HRCA, its members, officers, directors, employees, volunteers, agents, or any other representative of these entities against any and all causes of action, claims, demands, losses, expenses, ability as the result of my participation in the activity of horseback riding, pony rides, pony parties or hay wagon rides. This contract shall be legally binding upon my heirs, my estate, legal guardians, my representatives and me. UNDER COLORADO LAW, AN EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO, OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES PERSUANT TO SEC: COLORADO REVISED STATUTES I have carefully read this agreement and fully understand the contents. I am aware that I am releasing certain legal rights and thereby enter into this contract in behalf of myself and/or my family of my own freewill. Any photographs taken while participating in any program, recreational activity, or event are the property of the Highlands Ranch Community Association, Inc. and may be used at their discretion. RIDERS UNDER 18 YEARS OF AGE ARE REQUIRED TO HAVE PARENTS SIGNATURE. *Participant Name (Print) *Signature of Parent/Guardian *Date Page 11 of 12

12 Section C: Emergency Care and Transportation Emergency Care and Transportation Authorization: I grant authorization and consent for the Supervising Adult to administer general First Aid treatment for any minor injuries or illnesses experienced by the minor. If the injury or illness if life threatening or in need of emergency treatment, I authorize the Supervising Adult to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment or hospital care deemed advisable by, and to be rendered under the general supervision of, nay licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state which such treatment is to occur. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel. In the event of an emergency, I hereby give my permission for child care staff to access emergency medical services for my child, including transport to the nearest health care facility, to receive emergency medical or surgical care and treatment. It is understood that a conscientious effort will be made to locate me. I accept the expense of care and transport. *Signature of Parent/Guardian Date Page 12 of 12